2008-Issue1.indd Intraorbital Foreign Body: Clinical Presentation, Radiological Appearance and Management *Abdullah Al-Mujaini,1 Rana Al-Senawi,1 Anuradha Ganesh,1 Sana Al-Zuhaibi,1 Humoud Al-Dhuhli2 الشعاعي السريري، املظهر العرض العني: حجاج داخل غريب جسم العالجي والتدبير الذهلي حمود الزهيبي، سناء جانيش، انورادا السناوي، رنا ايني، اهللا عبد النادر ومن ، الصناعية احلوادث أو ــاص مثل طلقات الرص ــرعة الس عالية االصابات نتيجة عادة العني حجاج داخل ــام الغريبة األجس ــص: تدخل امللخ يلقي االستعادي التقرير هذا البصر. فقدان اسوأها األجسام الغريبة الى مضاعفات خطيرة هذه تؤدي ميكن أن بسيطة. اصابات بعد احلالة حدوث هذه من حيث ، عمان) (سلطنة قابوس السلطان جامعة ــفى مستش في ــافهما اكتش مت العني غريبة داخل ــام أجس مصابتني بدخول حالتني على الضوء وطرق اجلراحي واالجراء البصر حدة الدقيقة للحالتني مثل فحص التفاصيل ــجيل تس مت والتدخل اجلراحي. ــعاعي والتصوير الش ــريرية الس الصفات داخل العني الغريبة ــام االجس ــف عن وجود الكش مت وقد ، التوالي على ــنوات 9 س 10 و حادة هو بأدوات العني في اصيبا الذين املريضني عمر العالج. بعدها وتعافى ، فورا جراحية لعملية خضع حيث ، العني تتأثر األصابة ولم بعد مباشرة الينا املريض األول حضر للعني. املقطعية األشعة عن طريق وظائف جميع لذلك فقد املريض ، لَة ُقْ امل نِ اصابته بالتهاب بَاطِ وتبني االصابة بعد أيام بأربعة متاخرا حضر الينا فقد الثاني املريض أما بصورة كاملة. اجلسم ازالة ان سرعة كما ، مكانه وحتديد املقلة الغريب في اجلسم تقصي في مهما دورا تلعب بان األشعة املقطعية هنا االشارة يجدر املصابة. العني مضاعفات االصابة اخلطيرة. وتفادي العني على احملافظة على يساعد حيث ايجابية يؤثر بصورة جراحيا الغريب . عمان سلطنة ، حالة تقرير ، العني اختراق العني ، : اصابات الكلمات مفتاح Departments of 1Ophthalmology, 2Radiology & Molecular Imaging, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman *To whom correspondence should be addressed. Email: mujainisqu@hotmail.com SULTAN QABOOS UNIVERSITY MEDICAL JOURNAL MARCH 2008, VOLUME 8, ISSUE 1, P. 69-74 SULTAN QABOOS UNIVERSITY© SUBMITTED - 3RD SEPTEMBER 2007 ACCEPTED - 14TH JANUARY 2008 ABSTRACT Intraorbital foreign bodies usually occur after a high velocity injury such as gunshot or industrial accidents; more rarely they occur following trivial trauma. A retained foreign body can give rise to serious complications, the most devastating of which is loss of the eye. This retrospective, interventional case report reviews the clinical features, radiological appearance and surgical management of two patients who presented at Sultan Qaboos University Hospital, Oman with intraorbital foreign bodies. Details of ocular history, preoperative ocular examination findings including visual acuity, surgical procedure and subsequent management were noted. The two patients, aged 0 years and 9 years old respectively, sustained orbital trauma with sharp objects. Both patients were found to have intraorbital foreign bodies that were documented clearly by computed tomography (CT) scans of the orbit. The first patient presented straight after injury, had no ocular involvement, underwent immediate surgical exploration and ended up with full recovery. The second patient presented to us after a delay of 4 days, and was found to have endophthalmitis. This patient ultimately lost all visual function in the affected eye. A CT scan is the modality of choice for orbital foreign body detection and localization. Early surgical exploration and foreign body extraction greatly influence the visual prognosis and final outcome. Key words: Eye Injuries, penetrating; Case report; Oman. AN INTRAORBITAL FOREIGN BODY IS AN important cause of ocular morbidity espe-cially in the peadiatric and adolescent age groups. The term refers to a foreign body that occurs within the orbit but outside the globe.1 It usually occurs after a high velocity injury such as a gunshot or an in- dustrial accident, but even relatively trivial trauma can cause it.1 Orbital foreign bodies are more commonly observed in males than in females and in younger than in older patients. They can be classified according to C A S E R E P O R T A B D U L L A H A L - M U J A I N I , R A N A A L -S E N AW I , A N U R A D H A G A N E S H , S A N A A L - Z U H A I B I , H U M O U D A L - D H U H L I 70 their composition into a) metallic such as steel; b) nonmetallic, which may be inorganic such as glass; c) organic such as wood or vegetable matter. In general, metal and glass are well tolerated, and if not caus- ing any symptoms or signs, may be left in situ, while organic matter like wood and vegetable matters are poorly tolerated, elicits an intense inflammatory reac- tion, and need to be removed urgently.2 Surgery is planned based on certain aspects that include the nature of the intraorbital foreign body (poorly tolerated organic objects such as wood and vegetable matter, or well tolerated objects such as stone, glass, plastic, iron, steel and aluminum); loca- tion of the foreign body (anterior or posterior orbit), and presence of other injuries or foreign body-related complications (such as optic nerve compression, in- fections, and extraocular muscle involvement).3 Figure 1.1: Pre-operative face photos show moderate lid ptosis, normal position of the globe in primary gaze, and conjunctival hyperemia in left eye (1.1b), with marked limitation in adduction and abduction (1.1 a and c) 1.1a 1.1b 1.1c a b Figure 1.2: Computed tomography (CT) images of the orbits - Axial CT images through the orbits show: a) High density linear foreign body (straight arrow) within the medial rectus muscle of the left orbit; b) The medial rectus muscle is enlarged due to a hematoma. The distal tip of the foreign body is seen against the medial wall of the orbit (arrow head) Figure 1.3: Foreign body ( fish bone), the larger piece is 2.5cm, the shorter is 2.0cm I N T R A O R B I TA L F O R E I G N B O D Y : C L I N I C A L P R E S E N TAT I O N , R A D I O L O G I C A L A P P E A R A N C E A N D M A N A G E M E N T 71 C A S E R E P O R T S The hospital charts of two patients who sustained or- bital trauma, and who presented at the Ophthalmol- ogy Department of Sultan Qaboos University Hospital (SQUH), Oman, were retrospectively reviewed. C A SE  A 10-year-old boy presented with orbital trauma sus- tained when he was struck in the left eye while swim- ming by what he described as a flying fish. Ocular examintation showed a best corrected visual acuity of 20/20 in the right eye and 20/25 with -1.0 -0.75 x 75o in the left eye. Ophthalmic examination of his right eye was unremarkable. Examination of the left eye re- vealed ptosis and normal position of the globe in the primary gaze. There was lid oedema, conjunctival hy- peremia, chemosis and a laceration over the insertion of the medial rectus muscle. Limitation of movements in adduction and abduction was noted [Fig1.1a-c]. The globe itself was intact and slit lamp biomicroscopy showed normal intraocular structures. Computed to- mography (CT) scan of the orbits revealed the pres- ence of a hyper-dense foreign body dissecting the me- dial rectus, penetrating the periosteum and embedded in the left medial orbital wall [Fig 1.2]. The child was admitted and commenced on intra- venous ceftriaxone 1 gm daily and topical ofloxacin four times a day with a plan to intervene surgically. The foreign body was approached through transconjuc- tival medial orbitotomy. Intraoperatively, the foreign body was found transecting all the way postero-medi- ally towards the lacrimal bone. As it was very difficult to retrieve it in one piece, it was broken and extracted as two pieces (2.5 cm and 2.0cm in length) [Fig 1.3]. The globe was intact and the wound sutured with 6/0 vicryl suture. Post-operatively, topical Tobradex® eye drops were administered four times a day. An uneventful recovery was observed; the patient maintained normal visual acuity and regained full ocular motility in all directions within 2 weeks following surgery [Figs.1.4 and 1.5]. C A SE 2 A 9-year-old boy, who sustained trauma in the right eye with a pencil, presented to SQUH four days af- ter the trauma. Initial management at a local hospi- tal had included administration of topical antibiotics and steroids. Over the following days, he experienced increasing redness and reduced vision in the affected eye. At presentation, his left eye showed a visual acu- ity of 20/20 and normal intraocular findings. The ocu- lar examination of right eye revealed visual acuity of light perception with good projection, and lid oedema (lower lid more than upper) [Fig. 2.1]. No wound of entry was detected. Slit-lamp biomicroscopy revealed a hazy cornea, Figure 1.4: Face photo of same patient three days after intraorbital foreign body removal. Lid edema and ptosis are reduced (1.4b). Patient has mildy restricted adduction and abduction (1.4 a and c) 1.4a 1.4b 1.4c Figure 1.5: Two weeks post-operatively, the left eye looks normal in the primary position (1.5b). Patient has recovered normal adduction and abduction (1.5 a and c) 1.5a 1.5b 1.5c A B D U L L A H A L - M U J A I N I , R A N A A L -S E N AW I , A N U R A D H A G A N E S H , S A N A A L - Z U H A I B I , H U M O U D A L - D H U H L I 72 anterior chamber filled with a fibrinous reaction and a Indications - Large or sharp-edged foreign body - Signs of infection or inflammation - Proptosis - Restricted motility - Chemosis - Palpable orbital mass - Optic nerve compression - Abscess proved by imaging - Enhancing foreign body in imaging - Suspicion of a wood, vegetable matter or copper foreign body - Fistula formation Table 1: Indications for surgery in patients with intraorbital foreign bodies Figure 2.1: Photo of the right eye pre-operatively. It shows a swollen lower eyelid and an arrow pointing at possible location of foreign body in the lower lid a b Figure 2.2: Computed tomography (CT) images of the orbits - Axial CT images through the orbits show: a) High density linear foreign body (straight arrow) within the medial rectus muscle of the left orbit; b) The medial rectus muscle is enlarged due to a hematoma. The distal tip of the foreign body is seen against the medial wall of the orbit (arrow head) Figure 2.3: Foreign body: pencil tip, measuring 0.5 cm at its widest dimension Figure 2.4: Face photo after foreign body extrac- tion. The swelling has subsided and the wound has healed completely, leaving no deformity I N T R A O R B I TA L F O R E I G N B O D Y : C L I N I C A L P R E S E N TAT I O N , R A D I O L O G I C A L A P P E A R A N C E A N D M A N A G E M E N T 73 1-mm hypopyon, cataractous lens, and 3+ cells in the vitreous. Ophthalmoscopy revealed absent red reflex with no view of fundus details. B-mode ultrasound revealed medium amplitude echoes through out the vitreous with attached retina. A CT scan of the orbits showed a hyperdense foreign body embedded in the lateral 1/3 of the preseptal compartment of the right lower lid [Fig 2.2]. The child was admitted and received intravenous ceftriaxone 500 mg twice per day besides topical ofloxacin, Predforte ® eye drops and prednisolone tab- let 10 mg (0.5mg/kg) per day with a plan to intervene surgically. Intraoperatively, pars plana vitrectomy was performed to clear up the vitreous; endolaser photo- coagulation was delivered to seal up the retinal hole and an intravitreal antibiotic injection was given. To remove the intraorbital foreign body the child under- went subciliary inferior orbitotomy, which revealed the presence of a pencil tip that had penetrated the or- bital septum and was lying just in front of the inferior orbital wall [Fig 2.3 and 2.4]. Postoperatively, although the intraorbital foreign body was successfully removed, the eye went into sec- ondary hypotony with a vision of no light perception as sequelae of endophthalmitis. D I S C U S S I O N Two patients with orbital foreign bodies have been presented. Both patients gave a history of trauma with a sharp object (Case 1 while swimming and Case 2 while playing with a pencil). Both had foreign bodies located in their anterior orbit that were demarcated clearly by CT scans of the orbit. The first patient, who presented immediately, had no ocular involvement, underwent immediate surgical exploration and ended up with full recovery. The second patient presented to us after a delay of 4 days and was found to have endo- phthalmitis; extensive therapeutic (medical and surgi- cal) measures could not save the sight in this eye. The presence of endophthalmitis in this patient is sugges- tive of globe penetration, but preoperative imaging as well as intraoperative exploration did not reveal evi- dence of ocular penetration. However, a possibility of partial scleral penetration and then subsequent migra- tion of the foreign body and self-sealing of the scleral wound cannot be ruled out. The history of penetrating eyelid or orbital in- jury should always raise the suspicion of an embed- ded intraorbital foreign body, particularly if it is a high velocity injury. Clinically, the presentation var- ies, with the patient being asymptomatic or having visual disturbances (decreased vision, double vision), pain, or swelling. The nature of injury and foreign ob- ject can be elicited by detailed history. However, it is well-known that the severity of injury in penetrating trauma of the orbit is often underestimated in physical examinations.3 Therein lies the importance of a me- ticulous examination and radiological investigation. Assessment through radiological images assists in the proper localization of the foreign body, estimation of its consistency and size, and evaluation of the re- sponse of surrounding orbital tissue. Additionally, it is useful in determining the integrity of the globe. The choice of imaging modality chiefly depends on the na- ture of the suspected foreign body. Plain film radiog- raphy is useful to localize radiopaque objects.4, 5 How- ever, plain films lack the capacity to demonstrate the object details, their exact location in relation to sur- rounding structures and tissue response or damage. Standardized ophthalmic ultrasonography (combina- tion of standard A-mode and B-mode scanning) has been recommended as the imaging modality of choice during initial evaluation. Nevertheless, this diagnos- tic method requires specific expertise and technology that may not be available in many institutions.3 CT scanning has therefore been recommended as the im- aging modality of choice in this situation.1 Ideally, a CT scan of the orbit must be ordered. Thin axial and coro- nal views of 1.0-1.5 mm cuts of the orbit are extremely useful to delineate the shape and for determining the composition of the foreign body.6, 8 However, despite being highly sensitive and specific for detection of for- eign bodies, CT scans may produce false negative re- sults, particularly if the size of the foreign body is less than 0.5mm, and especially in the case of wooden ob- jects. These are better seen with magnetic resonance imaging (MRI). However, an MRI is contraindicated if the suspected foreign body is ferromagnetic. Once an intraorbital foreign body is diagnosed, ap- propriate management includes culture of the wound (or foreign body if removed) and administration of antibiotic(s). Tetanus toxoid has to be administered according to the vaccination status. In general, surgery to remove the foreign body is planned based on certain aspects, which are summa- rized in Table 1. In general, a posteriorly located for- eign body may be observed if inert and not causing any complications, due to the risk of iatrogenic optic A B D U L L A H A L - M U J A I N I , R A N A A L -S E N AW I , A N U R A D H A G A N E S H , S A N A A L - Z U H A I B I , H U M O U D A L - D H U H L I 74 neuropathy or diplopia. Similarly, small nonorganic foreign bodies may be left in the orbit. C O N C L U S I O N Detection of intraorbital foreign bodies requires a high index of suspicion. 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